Machine Learning in Medicine.

Are we about to be taken over by machines?

The first key step in realising any new technology in healthcare is communicating its value to both patients and healthcare staff. This can present a challenge when the discussion is around Machine Learning (ML) and Artificial Intelligence (AI) due to the associations, and often, misunderstandings, many people carry surrounding these terminologies. Nevertheless, informed patient consent in this area is vital and only fully informed when a decision has been made with the weighing up of accurate information. This is especially important in the issue of data ownership, where there can be confusion about what the implications of consent to 'use of data' means in healthcare today.

But if we can get beyond this issue of understanding and demystifying concerns about ML and AI then the vast benefits for modern medicine and the NHS are apparent; improved efficiencies in practice and resource management, enhanced precision and personalised medicine, more accurate diagnoses, treatments and prognoses.

Of course there are some concerns too that if ML algorithms are recognising patterns in large data sets and then spotting these same trends in new data then the alogortihm is only as good as the data it recieves. Currently the NHS IT infrastructure is fragmented and multi-layered which may pose challenges for acquiring reliable usable data. There may also be problems with algorithms overfitting to patterns in data and application may not suit the different context of primary and secondary care. Algorithms may also make mistakes, and keeping track of the reasoning and logic behind their outputs may be difficult and may limit how much their credibility and acceptance is seen in practice.

This technology will undoubtedly disrupt ways of working in modern medicine - but as human oversight is vital it can only be successful when applied in collaboration and partnership with clinicians and healthcare staff. For example, the role of a radiologist will likely change to more of a supervisor overseeing algorithms reporting hundreds of scans and clarifying discrepancies, but then, new roles and responsibilities will emerge in these new ways of working...more interventional working, or perhaps even more patient-facing care?

Underpinning all of this is of course the issue of accountability and where liability sits with the use of such technology. Will the clinician be responsible? Or the manufacturer? Or the healthcare provider? Whatever the end-point it seems now is a crucial time to bring together clinicians, industry and policy makers to support the development of governance regulation and standards to ensure the potential of this technology can be realised, but also trusted by society.

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Introduction
GPs for a little while have been asked to compare each other’s outpatient referrals rates. The idea is that this peer to peer open review will help us understand each others referral patterns. For some reason and due to a natural competitive nature of human behaviour, I think we have these peer to peer figures put to us to try to get us to refer less into hospital outpatients.
It’s always hard to benchmark GP surgeries but outpatient referral benchmarking is particularly poor for several reasons
It's Very Difficult to Normalise Surgeries
Surgeries have different mortalities morbidities ages and other confounding factors that it becomes very hard to create an algorithm to create a weighting factor to properly compare one surgery against another.
There Are Several Reasons For The Referral
I’ll go into more detail on this point later but there are several reasons why doctors refer patients into hospital which can range from: doctors knowing a lot about the condition and picking up subtle symptoms and signs lesser experienced doctors would have ignored; all the way to not knowing about the condition and needing some advice from an expert in the condition.
We Need To Look At The Bigger Picture
The biggest killer to our budget is non-elective admissions and it’s the one area where patient, commissioner and doctor converge. Patients want to keep out of hospital, it’s cheaper for the NHS and Doctors don’t like the lack of continuity when patients go in. For me I see every admission to hospital as a fail. Of course it’s more complex than this and it might be totally appropriate but if we work on this concept backwards, it will help us more. Likewise if we try to reduce outpatient referrals because we are pressurised to, they may end up in hospitalisation and cost the NHS £10,000s rather than £100s as an outpatient. We need to look at the bigger picture and refer especially if we believe that referrals will lead to less hospitalisation of patients further down the line. To put things into perspective 2 symptoms patients present which I take very seriously are palpitations in the elderly and breathlessness. Both symptoms are very real and normally lead to undiagnosed conditions which if we don’t tackle and diagnose early enough will cause patients to deteriorate and end up in hospital.
Education, Education, Education
When I first went into commissioning as a lead in 2006 I had this idea of getting to the bottom of why GPs refer patients to outpatients. The idea being if we knew why, we would know how to best tackle specialities. I asked my GPs to record which speciality to refer to and why they referred over a 7 month period. The reason for admission was complex but we divided them up into these categories:
2nd care input required for management of the condition. We know about the condition but have drawn the line with what we can do in primary care. An example of this is when we’ve done a 24 hour tape and found a patient has 2sec pauses and needs a pace maker.
2nd care input required for diagnosis. We think this patient has these symptoms which are related to this condition but don’t really know about the diagnosis and need help with this. An example of this is when a patient presents with diarrhoea to a gastroenterologist There could be several reasons for this and we need help from the gastroenterologist to confirm the diagnosis via a colonscopy and ogd etc.
Management Advice. We know what the patient has but need help with managing the condition. For example uncontrolled heart failure or recurrent sinusitis.
Consultant to Consultant Referral. As advised between consultants.
Patient Choice. Sometimes the patient just wants to see the hospital doctor.
The results are enclosed here in Excel and displayed below. Please click on the graph thumbnail below.
Reasons For Referrals
Firstly a few disclaimers and thoughts.
These figures were before any GPSI ENT, Dermatology or Musculosketal services which probably would have made an impact on the figures.
There are a few anomalies which may need further thought eg I’m surprised Rheumatology for 2nd input for diagnosis is so low, as frequently I have patients with high ESRs and CRPs which I need advise on diagnoses. Also audiology medicine doesn’t quite look right.
The cardiology referral is probably high for management advise due to help on ECG interpretation although this is an assumption.
This is just a 7 month period from a subset of 8-9 GPs. Although we were careful to explain each category and it’s meaning, more work might need to be done to clarify the findings further.
In my opinion the one area where GPs need to get grips with is management advice as it’s an admission that I know what the patient has and need help on how to treat them. This graph is listed in order of management advice for this reason.
So what do you do to respond to this? The most logical step is to education GPs on the left hand side of this graph and invest in your work force but more and more I see intermediary GPSI services which are the provider arm of a commissioning group led to help intercept referrals to hospital. In favour of the data most of the left hand side of the graph have been converted into a GPSI service at one point. In my area what has happened is that referrals rates have actually gone up into these services with no decline in the outgoing speciality as GPs become dis-empowered and just off load any symptoms which patients have which they would have probably had a higher threshold to refer on if these GPSI services were not available. Having said that GPSI services can have a role in the pathway and I’m not averse to their implementation, we just have to find a better way to use their services.
3 Step Plan
As I’m not one to just give problems here are my 3 suggestions to help referrals.
To have a more responsive Layered Outpatient Service.
Setting up an 18 week target for all outpatients is strange, as symptoms and specialities need to be prioritised. For example I don’t mind waiting 20 weeks for a ENT referral on a condition which is bothering me but not life threatening but need to only have a 3 week turn over if I’m breathless with a sudden reduction in my exercise tolerance. This adds an extra layer of complexity but always in the back of my mind it’s about getting them seen sooner to prevent hospitalisation.
Education, education, education
It’s ironic that the first budget to be slashed in my area was education. We need to education our GPs to empower them to bring the management advice category down as this is the category which will make the biggest impact to improving health care. In essence we need to focus on working on the left hand side of this graph first.
Diagnose Earlier and Refer Appropriately
The worst case scenario is when GPs refer patients to the wrong speciality and it can happen frequently as symptoms blur between conditions. This leads to delayed diagnosis, delayed management and you guessed it, increased hospitalisation. The obvious example is whether patients with breathlessness is caused by heart or lung or is psychogenic. As GPs we need to work up patients appropriately and make a best choice based on the evidence in front of us. Peer to peer GP delayed referral letter analysis groups have a place in this process.
Conclusion
At the end of the day it's about appropriate referrals always, not just a reduction.
Indeed for us to get a grip on the NHS Budgets as future Clinical Commissioners, I would expect outpatient referrals to go up at the expense of non-elective, as then you are looking at patients being seen and diagnosed earlier and kept out of hospital.

The Birmingham Student’s Medical Leadership Society (MLS) held it’s third and final lecture of 2013 on Thursday December 5th. The final lecture was given by Dr Mark Newbold CEO of the Heart of England NHS Foundation Trust and was a particularly enlightening end to our autumn lecture series on why healthcare professionals should become involved in management and leadership. In contrast to the previous talk by Mr Tim Smart this lecture did not focus on why doctors would be suitable for management roles but rather on why clinical leadership is absolutely necessary to tackle the fundamental problems in our hospitals today.
Once again, the Birmingham MLS heartily thanks Dr Newbold for giving up his valuable time to speak to us and we must also thank Michelle and Angie for video recording this event as well. Fingers crossed, the recordings of both of our last events should be available fairly shortly.
The lecture began with a brief career history of why and how Dr Newbold became involved in hospital management, from front line doctor, to department lead and on to chief exec of a major NHS foundation trust.
The second part of the lecture was a brief history of the recent NHS beginning with the Labour years. Between 1997 and 2010 NHS funding increased enormously, which was a good thing. Targets increased proportionally with the funding, not necessarily a good thing. Expectations to meet the targets at all costs and punishments for failure also increased, not a good thing. Focus became diverted from providing the best possible care to ensuring that the hospital didn’t go bankrupt from failing to hit it’s targets. The “budget culture” was an unintended consequence of overzealous central target setting.
This system did have some major successes, such as overall reduced waiting times and new specialist urgent cancer referral pathways. However, these successes did not necessarily transform into better patient care or higher patient satisfaction. This came to ahead as well all know with the Mid-Staffs Enquiry, the Francis report and the Keogh review.
The recent NHS reforms have tried to change the NHS management culture away from target driven accounting and more towards affordable, yet excellent patient care – a “quality culture”. The NHS structural reforms have been well meaning but messy and complicated. The NHS culture change has begun, but trying to change something as huge as the NHS is like trying to steer an oil tanker, it takes time for the tiniest change in direction to be noticed. Add to this list of changes, an ever ageing population, an ever growing population, an increasingly chronically ill, co-morbid population and a relative freeze in budget and you can start to see why NHS managers are having such a tough time at the moment.
How can NHS managers adopt this culture?
Put their priorities in order. Quality care + Patient satisfaction > Waiting lists > Budgets
Engage with the public in a more meaningful way. Have a social media presence so that you, your hospital and its staff are more than just a faceless organisation. Have a twitter account and write blogs about your challenges and successes. This will increase patient satisfaction with your hospital.
Ask for and listen to patient reviews regularly. Make sure these reviews are public and this will help ensure that any changes made are recognised.
Better articulate why you are changing a service, e.g. you are not shutting a local A/E to save money but to save lives! Specialist centres have been shown to have better patient outcomes than smaller, less specialised centres. The London stroke service reforms are an excellent example of this principle.
Realise that a budget is a constraint, not an aim!
Create a dialogue with doctors about which targets are important and why they are important. If doctors don’t agree with the targets then they will not try to improve the measures. For example, the A/E 4 hour waiting time target annoys a lot of healthcare professionals, who see it as a criticism of their work. However, this target is in fact not a measure of A/E efficiency but actually a measure of FLOW through the entire hospital. If the 4h target is missed then there is a problem within the hospital system as a whole and the doctors needed to be aware that their service is reaching capacity and that this may affect their practice. They should also consider why the 4h target was missed and what can they do to increase the patient flow through the hospital – are they needed in an understaffed department?
The essence of this part of the lecture can be summarised by saying that “poor hospital performance has consequences for that hospital and its staff, these consequences affect clinical care and therefore, healthcare professionals need to care about the bigger picture otherwise it will affect frontline care”.
The next part of the talk went on to outline some of the recent problems that Dr Newbold has been made aware of and how this affects his hospitals performance.
35% of patients who present to the A/E department have at least 1 chronic condition.
12% of patients are re-admitted within 30 days. Did they receive suboptimal care the first time?
Patients who are re-admitted have a far higher mortality rate than other patients.
Once, a patient has been in hospital for longer than 5 days their mortality rate begins to rise drastically. Being in a hospital is bad for your health and patients are often not discharged as soon as they should be.
A hospital of 1500 people needs to discharge over 200 patients a day just to maintain its flow of patients. If this discharge rate decreases then the pressure on the system increases and beds are no longer available, which starts to decrease the services a hospital can provide, such as elective operations.
Hospitals tend to be managed on 4 layers of alert. When the hospital is on top alert i.e. the most under pressure, mortality rates can be up to 8% higher than when the hospital is at its least pressured.
By not discharging patients promptly, doctors are increasing the pressure on the system as a whole with awful unintended consequences for the patients.
By admitting patients to the wards, who do not necessarily require in-patient care, doctors are also increasing the pressure on the system. Bed blocking has consequences for the patients, not just the budgets.
The list above demonstrates how unintended consequences of frontline staff decisions affect patient outcomes. That is why it is critical that frontline staff are involved with helping to improve some of these problems. Does that patient really need to be admitted to an already full hospital? Does that patient really need to stay on the ward until Friday? Did that man with an exacerbation of asthma get the best acute treatment and has a plan been made for his long term management that will decrease the chance of him re-admitting? Healthcare staff can help by adjusting their practice to the situation and by helping to change the systems overall, so that the above consequences are less likely to occur.
This part of the lecture was really quite sobering. It spelled out some hard facts about how such a complex system as a hospital operates. But more importantly it helped clarify just what needs to be done in the future to make hospital care the best it can be. Dr Newbold quoted the RCP report “Hospitals are not the problem, they have a problem” to highlight his believe that in the future the health service needs to change to be less focussed on acute crises and more focussed on exacerbation prevention. Hospitals should be a last resort, not a first choice.
Hospitals themselves need to change how they deliver care. NHS staff need to explore ways of providing their services in an ambulatory fashion, so that patients don’t need to stay on the wards for any pre-longed period of time but come and go as quickly as possible. This will involve a major shake up in how hospital trusts fund care. They will need to increase their funding for the provision of more services at home. They need to get their employs out of the hospital and into the community. They need to work more closely with GP’s and with local social services. As the previous Chief Medical Officer said “Good Health is about team work”. Only when GP’s, community staff, hospital staff and social services work as a team will patient care really improve.
At the present The University of Birmingham Students Medical Leadership Society is in contact with the FMLM and other similar groups at the Universities of Bristol, Barts and Oxford. We are looking to get in contact with every other society in the country. If you are a new or old MLS then please do get in touch, we would love to hear from you and are happy to help your societies in any way we can – we would also love to attend your events so please do send us an invite.
Email us at med.leadership.soc.uob@gmail.com
Follow us on Twitter @UoBMedLeaders
Find us on Facebook @ https://www.facebook.com/groups/676838225676202/
Come along to our up coming events…
Wednesday 22nd January 2014 LT3 Medical School, 6pm
‘Has the NHS lost the ability to care?’ – responding to the Mid Staffs inquiry’
By Prof Jon Glasby, Director of the Health Services Management Centre , UoB
Thursday 20th February LT3 Medical School, 6pm
‘Reforming the West Midlands Major Trauma Care”
By Sir Prof Keith Porter, Professor of Traumatology, UHB
Saturday 8th March WF15 Medical School, 1pm
“Applying the Theory of Constraints to Healthcare”
By Mr A Dinham and J Nieboer ,QFI Consulting